Application for Education Support Staff Employment

Transcription

1 HAMPTON UNIVERSITY HAMPTON, VIRGINIA Application for Educational Support Staff Employment OFFICE OF HUMAN RESOURCES Room 110, Armstrong-Slater Application for Education Support Staff Employment Date: Position(s) applied for (Check one or more) Clerical Skilled Regular Full-time Fiscal and Administrative Semi-skilled Regular Part-time Professional and Technical Unskilled Temporary Referral Source: Advertisement Friend Relative Walk-in Employment Agency Other PLEASE PRINT OR TYPE PERSONAL Name Last First Middle Initial Address Number Street City State Zip Code Telephone Number ( ) Social Security Number Area Code Name and address of person to notify in case of an emergency: Name Last First Middle Initial Address Number Street City State Zip Code Telephone Number ( ) Area Code Are you related to any person employed or who is a student at Hampton University? Yes No If yes, list. Name Name Department Department Relation Relation An Equal Opportunity Employer - 1 -

2 PERSONAL REFERENCES Do not list former employers or relatives Name Address Telephone Number If employed and you are under 18, can you furnish a work permit? Yes No Have you filed an application here before? Yes No If yes, give date. Have you ever been employed here before? Yes No If yes, give date. Department _ Title Are you currently employed? Yes No May we contact your employer? Yes No Will you be able to provide a birth certificate or proof of U.S. Citizenship? Yes No (Proof of citizenship or immigration status may be required upon employment. See page 5.) On what date would you be available for work? Can you travel if a job requires it? Yes No Have you ever been convicted of a crime, excluding minor traffic violations? Yes No If Yes, please provide details concerning conviction, including original charge, the conviction, and the disposition and any explanation you deem appropriate. Convictions will not necessarily exclude you from employment, but the date and type of conviction will be considered for job placement

3 MILITARY SERVICE RECORD Have you ever served in the armed forces? Yes No If Yes, what branch? Dates of duty: From To Month Day Year Month Day Year Type of discharge If not honorable, explain Are you a veteran? Yes No Are you a reservist? Yes No If Yes, what is your status? Active Inactive Retired LICENSES AND SPECIAL SKILLS Do you have a valid Virginia driver s license? Yes No Do you have a valid driver s license from any other state? Yes No If Yes, please list state. Do you have any professional or occupational licenses? Yes No If Yes, please list. Do you operate any machines or equipment? Yes No If Yes, please list. Do you type? Yes No If Yes, please list WPM. Do you take shorthand or speedwriting? Yes No If Yes, please list WPM. List any other special skill(s) EDUCATIONAL BACKGROUND Type of School Name and Address Years Attended Graduated Course or Major Grammar or Grade High School College (Undergraduate) (Graduate) Other - 3 -

4 ACTIVITIES List professional, trade, business or civic activities in which you engage and any offices held. (Please exclude those which indicate race, color, religion, sex or national origin): OCCUPATIONAL RECORD Start with your last position and work back. (If you were ever employed in any position under a different name, give in each position, the name used.) Employer Address Position or Title From To The fact that you may have been discharged or forced to resign from a position will not necessarily disqualify you from employment. Please give reason for leaving each past position, including your current one: Use the space below to summarize any additional information necessary to describe your previous employment that will help us fully determine your qualifications

5 NOTICE OF NONDISCRIMINATION Hampton University is an Equal Employment Employer and as such, does not discriminate against any individual based upon race, color, national origin, sex, age or handicap in fostering its programs, employment practices and activities. Employment qualifications for all positions shall be based only on job requirements as set forth by the University. It is the policy of the University to provide Equal Employment Opportunity in all aspects of employer/employee relationships including recruiting, hiring, upgrading and promoting. The director of University Testing Services is the University s Coordinator of Section 504 of the Rehabilitation Act of 1973 and Title VI of the Civil Rights Act of 1964, and Title IX of the Education Amendments of The office is located in Room 212, Wigwam Building, and the telephone number is (757) Office hours are 8 a.m. to 5 p.m., Monday thru Friday. APPLICANT S CERTIFICATION AND AGREEMENT (Please read the information carefully and ask for assistance if required before signing.) I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I authorize Hampton University to make any investigation of my past and present work, character, education, financial and credit records, military and police records through any appropriate investigative or credit agencies or bureaus. I understand that my offer of employment is conditioned upon the results of the investigation. I agree that the final step in the application process may be the administering of certain tests, including medical, clerical, technical or other tests that will determine my eligibility for the position(s) for which I apply. I agree, if employed, to abide by all policies and procedures set forth by Hampton University that will affect my employment. I agree, if employed, to furnish the document(s) listed below within seventy-two (72) hours of employment for Employment Eligibility Verification (I-9 Form). 1. U.S. Passport 2. Certificate of U.S. Citizenship 3. Certificate of Naturalization List A OR List B AND List C 4. Unexpired foreign passport with INS Form I Alien Registration Receipt Card (INS Form I-151 or I-551) 6. Unexpired Temporary Resident Card (INS Form I-688) 7. Unexpired Temporary Authorization Card (INS Form I- 688A) 8. Unexpired Reentry Permit (INS Form I-327) 9. Unexpired Refugee Travel Document (INS Form I-571) 10. Unexpired Employment Authorization Document issued by INS with photo (INS Form I-688B) 1. Driver s License or state ID card containing photo 2. ID card issued by federal, state or local government 3. School ID card with photo 4. Voter s registration card 5. U.S. Military ID card 6. Military Dependent s ID card 7. U.S. Coast Guard Merchant Mariner card 8. Native American Tribal document 9. Driver s license issued by a Canadian government authority (For persons under age 18 who do not have above listed documents:) 10. School record or report card 11. Clinic, doctor or hospital record 12. Day-care or nursery school record 1. U.S. Social Security Card 2. Certification of Birth Abroad issued by State Department 3. Original or certified copy of birth certificate 4. Native American tribal document 5. U.S. Citizen ID Card (INS Form I-197) 6. ID Card for use of Resident Citizen in the U.S. (INS Form I-179) 7. Unexpired employment authorization document issued by the INS (other than those listed under List A) Signature: Date: - 5 -